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Program Details

SANOFI
Sanofi Patient Connection

Lantus (insulin glargine)
 
CONTACT INFO
Address: PO Box 222138
Charlotte, NC 28222-2138
Phone: 1-888-847-4877 Provider Phone:
Fax: 1-888-847-1797 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patient must have no insurance coverage or access to the prescribed product or treatment via their insurance.
  • Patients with Medicare Part D may be eligible, contact program for details.
  • Income at or below: Single 400 % FPL
      Couple 400 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    Medicaid denial letter
    Physician License #
    Required:
    State
    NPI
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Both Provider and Patient
    MEDICATION
    Receives: Medication
    Shipped To: Provider
    Quantity in Shipment: Not Published
    Delivery Time: 0-1 week
    Re-application Policy: New application every 12 months
    New financial information every 12 months
    Refill Policy: A refill form must be faxed to program.
    Other Information:

    Last Updated: 06/17/2021

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    DocumentForm (English)



     

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